CMS recently issued a transmittal providing guidance to Medicare program contractors on when and how to refer certain “recalcitrant providers” to CMS for potential sanctions under the Office of Inspector General’s (OIG) civil monetary penalty and exclusion authorities.  CMS instructs contractors that believe they have a recalcitrant provider case to contact their CMS regional office as well as the Center for Program Integrity’s Fraud and Abuse Sanctions and Suspensions (FASS) team.

The transmittal revises parts of Chapter 4 of the Medicare Program Integrity Manual—effective January 15, 2014—to clarify the referral process for recalcitrant providers.  CMS defines “recalcitrant providers” as providers that are “are abusing the [Medicare] program and not changing inappropriate behavior even after extensive education by Medicare contractors to address these behaviors.”  Monitoring such providers through prepayment medical review, CMS notes, diverts resources away from other valuable contractor oversight activity.  According to the transmittal, a contractor should refer a provider case under the following circumstances:

The provider is not under an active OIG fraud investigation or under investigation by a Program Safeguard Contractor/Zone Program Integrity Contractor;

  • The provider is already on prepayment medical review and has continued to demonstrate a “pattern of inappropriate behavior” despite having received education to address the behavior;
  • The contractor can specify the administrative cost of claims being manually reviewed and denied;
  • The appeal history of the provider’s denied claims reflects a low reversal rate; and
  • The medical director concurs with the medical review determinations and understands that he or she may be called as a witness in the provider’s case.

The transmittal also provides criteria for CMS’s approval or disapproval of a recalcitrant provider referral and sets out the formatting contractors are to use when making a referral.

To view CMS’s transmittal, click here.